Magistrate Form | Neighborhood Dispute Settlement

Uniform Referral

Magisterial District Judge

Magisterial District Court No.

Judge's Name

Street Address

City/Postal Code

Phone

Fax

Docket No.

Date of Incident

Date of Initial Hearing

Date of Next Hearing

Additional Information

PARTY 1 INFORMATION

Party 1 Name

Party 1 Street Address

Party 1 City/Postal Code

Party 1 Phone

PARTY 2 INFORMATION

Party 2 Name

Party 2 Street Address

Party 2 City/Postal Code

Party 2 Phone

(For matters involving more than 2 parties, please use the fields below. If only two parties, jump to the bottom. Please review your information before submitting.)

PARTY 3 INFORMATION

Party 3 Name

Party 3 Street Address

Party 3 City/Postal Code

Party 3 Phone

PARTY 4 INFORMATION

Party 4 Name

Party 4 Street Address

Party 4 City/Postal Code

Party 4 Phone

PARTY 5 INFORMATION

Party 5 Name

Party 5 Street Address

Party 5 City/Postal Code

Party 5 Phone

In the above cited matter, I have referred these parties to Neighborhood Dispute Settlement for mediation services. I have reviewed my information and included all information relevant to this matter.

Your Signature

Thank you! We have received your form!

Uniform Referral

Magisterial District Judge

Please allow forty-five (45) to sixty days (60) for resolution of this matter through mediation.

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Building 1 | Suite 211
Harrisburg, PA 17102
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